Follow Up of the Agreed Actions from previous Health and Safety audits

City of York Council

Memorandum

For: Assistant Director of Customers and Employees, Head of Health and Safety Status: Final Date Issued: 27th July 2016

Where information resulting from investigation and/or audit work is made public or is provided to a third party by the client or by Veritau then this must be done on the understanding that any third party will rely on the information at its own risk. Veritau will not owe a duty of care or assume any responsibility towards anyone other than the client in relation to the information supplied. Equally, no third party may assert any rights or bring any claims against Veritau in connection with the information. Where information is provided to a named third party, the third party will keep the information confidential. 1 INTRODUCTION

1.1 Under the Health and Safety at Work etc Act 1974 and associated legislation the council has a responsibility for the health, safety and welfare of all its employees as well as customers accessing services.

1.2 The Health and Safety team are appointed, under the Management of Health and Safety at Work Regulations 1999 to advise the council in relation to its responsibilities regarding health and safety and also assists in the development of the Safety Management System (SMS), by advising on health and safety matters. The team does this by working with managers who are responsible for health and safety within their area of control, and the Workforce Development Unit who coordinate health and safety training across the council.

1.3 The Head of the Health and Safety service is shared between City of York Council and North Yorkshire County Council. This sharing arrangement is a formal agreement with the manager splitting their time between the two authorities, with at least two days a week to be spent at City of York Council; the manager also being available on other days depending upon the nature of the work. As of late August 2016, the whole of the Health and Safety service will be shared with North Yorkshire County Council with the other 5 members of the CYC Health and Safety Service also seconded to North Yorkshire County Council. A formal Service Level Agreement will be drafted and clear performance standards will be in place between the two councils.

Scope and Objectives

1.4 The objective of this audit was to determine the progress made towards the outstanding actions agreed by the management of the Health and Safety service to address one finding identified in the 13/14 audit and the findings identified in the 14/15 audit.

1.5 The audit reports for 13/14 and 14/15 have been provided in Annex 1 and 2 for reference. Full details of identified issues, risks and agreed actions can be found in these reports.

Key Findings

1.6 It was found that reasonable progress has been made towards the agreed actions but that there are a number of outstanding issues for which timescales have been revised and/or the appropriateness of the action which was originally agreed has been reviewed.

1.7 The detailed findings in each area are set out below and where action is still required this is set out in the action plan at appendix 1. 2 FINDINGS

Area Reviewed: Lone working risk assessments

2.1 The 13/14 audit of the Health and Safety (H&S) service found that a number of service areas who had an element of lone working did not have formal risk assessments or workplace instructions in place.

2.2 The action agreed with the previous Health and Safety manager at that time has not been completed and is not considered feasible. Therefore, two other actions have initially been proposed and these are detailed in points 1-2 of the Action Plan in Appendix 1.

Area Reviewed: Coverage of Health and Safety services for council properties

2.3 The 14/15 audit found that the documentation resulting from asbestos reviews, fire risk assessments, etc. was stored in multiple file areas. The service now uploads these documents to Techforge (asset management software system) and stores these documents by site rather than file type. This element of the action can be considered as complete.

2.4 The audit also found that there wasn’t a comprehensive premises register in place detailing the health and safety obligations of the council. It was agreed that a review would be undertaken to establish H&S obligations for each council property/service area. This review has not taken place and no assurance can be given that all properties are receiving the required H&S services.

2.5 There is a lack of a corporate approach to the management of the health and safety obligations of the council. These obligations are the responsibility of a number of service areas operating in isolation, including the corporate H&S team, Property Services, Facilities Management and Housing. Therefore, there can be no assurance that they are undertaking their responsibilities consistently and comprehensively.

2.6 In the case of leased council property, the service also faces the obstacle of historical lease documents, which do not specify the H&S obligations of the council and leaseholder for some council owned commercial properties. A guidance document is now issued to new tenants of these properties, stating that they are responsible for the monitoring of water, electrical and fire related risks but that the council has some responsibility for asbestos monitoring. This issue is addressed in ‘Asbestos Reviews’ (2.20 – 2.21).

2.7 Appropriate actions, responsible officers and timescales need to be agreed to address the requirements of this finding. Three actions have initially been proposed and these are detailed in points 3-5 of the Action Plan in Appendix 1. Area Reviewed: Health and Safety audits – coverage, follow ups and escalation

2.8 The 14/15 audit found Health and Safety audit reports were not always followed up within a reasonable timeframe or escalated where actions had not been completed. It was agreed that the reporting and escalation process would be revised. A new escalation policy has been approved and is published on the council intranet. Audit sites are now required to complete an action plan within 30 days of the visit, detailing how they are going to meet the requirements of findings and to what timescale. The H&S auditor reviews these plans to ensure that the proposed timescales are proportionate to the action. If the site fails to submit an action plan, or if they suggest a timescale which is not proportionate to the action, the issue will be escalated to relevant service heads and assistant directors. These actions satisfactorily address the issue previously identified and there is now an improved management of risk.

2.9 The 14/15 audit also found that agreed actions from H&S audits were not given a risk rating to indicate the importance of the action and how follow up processes should be concentrated. Actions are now rated by importance using priorities 'high', 'medium' and 'low'.

2.10 The 14/15 audit also found that over a third of sites that had been given a high risk rating on the audit programme had not been visited in over 4 years and a number of sites had never been visited at all. It was agreed that the audit programme would be reviewed and revised. Follow up testing demonstrated that all high risk sites have now either been visited in the previous two years or have visits booked in for 2016 or 2017. The percentage of premises which have never been visited on the audit programme has also reduced from 42% to 6%. These actions satisfactorily address the issue previously identified and there is now an improved management of risk.

2.11 It should be noted that the service implements a follow up process to ensure completion of action plans rather than individual actions. Following audits, services are required to return an action plan to the H&S auditor within 30 days. Actions are then checked for completion during the next audit.

Area Reviewed: Reporting of incidents under RIDDOR

2.12 The 14/15 audit found that there were significant delays in the reporting of incidents to the Health and Safety Executive (HSE) under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR). It was agreed that an ICT system for the reporting of accidents and incidents would be put in place, with the functionality for production of management information. The Incident Portal was successfully launched in April 2016.

2.13 Whilst there is not sufficient data available yet to determine whether this software will have a positive impact on the timeliness of RIDDOR submissions, automation increases the likelihood of managers submitting incident details to the required timescale. Management information will also allow the H&S service to target repeat offenders. The service has met the requirements of the agreed action and therefore, it can be considered as complete. However, ongoing monitoring is required to ensure effective management of this risk.

**Area Reviewed: Follow up of incident investigations**

2.14 The 14/15 audit found that no follow up of incident investigations was undertaken to ensure that the circumstances leading to the incident had been rectified. It was agreed that a review would be undertaken of the reporting and escalation process. The H&S auditor now produces a monthly report which is circulated to the Chief Executive, Directors and Assistant Directors, listing current incident investigations and whether they have been completed. In the future, this will be replaced by a report automatically generated from the new incident reporting system. The system has an action tracking feature which will prompt managers to complete actions. If the action is still outstanding after four weeks, an email will be automatically generated to notify the relevant assistant director. The software will also allow H&S staff to amend the details and timescales of actions to ensure that they are appropriate to the severity of the incident.

2.15 There was not enough data available at the time of this audit to establish whether actions are being tracked until completion, however, the functionality of the new software increases the likelihood that the H&S service will be able to implement an effective follow up process. The service has met the requirements of the agreed action and, therefore, it can be considered as complete. However, ongoing monitoring is required to ensure effective management of this risk.

**Area Reviewed: Contracts and framework agreements**

2.16 The 14/15 audit found that there was no contract or framework agreement in place for asbestos reviews and work and that new contracts needed to be put in place for water monitoring and fire risk assessments. There are now contracts in place for asbestos reviews and fire risk assessments and a water monitoring provider is accessed via the North Yorkshire County Council framework agreement. These actions satisfactorily address the issue previously identified and there is now an improved management of risk.

**Area Reviewed: Fire risk assessment (FRA) follow ups**

2.17 The 14/15 audit found that risk ratings were not given to actions or properties to indicate which actions should be completed and followed up as a priority. Actions are now assigned a risk rating, either 'high', 'medium' or 'low' and guidance is given as to the required completion timescales for each rating. The Health and Safety Advisor specialising in Fire Safety is in the process of assigning risk ratings to properties in her premises register.

2.18 It was also found that actions resulting from fire risk assessments were not followed up in a manner that would provide the council with assurance over the management of fire risk. It was agreed that a formal mechanism of reviewing fire risk assessments would be implemented and that areas of significant risk which had not been addressed in a timely manner would be escalated. The FRA officer implements a generally risk based approach to follow ups of actions arising from assessments, requesting the assessed properties to provide her with a completed action plan and notifying the relevant assistant directors if she considers their management of fire risk to be unacceptable. However, the follow up and escalation process is not formalised and there are no stated parameters to indicate when these processes should be triggered.

2.19 Revised completion dates have been agreed for these actions, please see points 6-7 of the Action Plan in Appendix 1.

2.20 It should be noted that the service implements a follow up process to ensure completion of action plans rather than individual actions. Following assessments, services are required to return an action plan to the H&S adviser within 30 days. Actions are then checked for completion during the next assessment.

Area Reviewed: Asbestos reviews

2.21 The 14/15 audit found that it was not always possible to identify up to date annual asbestos reviews and/or management plans for council occupied non-domestic premises. It was agreed that the Asbestos and Legionella Officer would complete a review of the asbestos register and associated management plans to ensure they were in place for all relevant properties. Testing demonstrated that there are still properties without this documentation in place, due to either the Asbestos and Legionella Officer being unaware of whether the council is responsible for leased commercial properties, or the property potentially being missed during the review.

2.22 The guidance document issued to new tenants of commercial properties states that the council will provide an asbestos survey when they move in and will arrange regular safety checks where asbestos is present. The corporate Health and Safety team will provide these checks when requested by Property Services. The lack of asbestos documentation available for commercial properties would suggest that this requirement is not being effectively communicated.

2.23 A revised completion date has been agreed for this action, please see point 8 of the Action Plan in Appendix 1.

Area Reviewed: Asbestos and Legionella representatives

2.24 The 14/15 audit found that there were no up to date lists of site representatives for asbestos (SALOs) and legionella (SLRs) or officers assigned the responsibility for these across the council. It was agreed that representatives would be established for each site. Corporate representatives have now been assigned and they are due to receive the relevant mandatory training in July 2016. This action satisfactorily addresses the issue previously identified and there is now an improved management of risk.

2.25 The Asbestos and Legionella Officer has updated the list of SALO and SLR representatives for school sites, however, there are still no representatives in place for any other site. Annual review forms are often sent to the H&S service with the ‘responsible officer’ field blank, suggesting that it is difficult to persuade employees to take ownership of these responsibilities. It is recommended that the service challenges sites that are unwilling to nominate a representative and that this is escalated to the corporate representatives as required.

2.26 A revised completion date has been agreed for this action, please see point 9 of the Action Plan in Appendix 1.

Area Reviewed: Legionella monitoring

2.27 The 14/15 audit found that insufficient monitoring information was received from the water monitoring provider to ensure that the required testing was being completed. It was agreed that the Asbestos and Legionella Officer would check the performance of the contractor on a bimonthly basis to ensure that this monitoring information was up to date. The documentation demonstrating the completion of monthly monitoring and annual water sampling was available for all properties tested. In the majority of cases, documentation was also available for the biannual water risk assessments. Whilst the monitoring information is not totally comprehensive, improvements have been made and the risk has been satisfactorily reduced. It is suggested that the service continues to monitor the performance of the contractor to ensure the completion of testing and successful upload of documentation.

Area Reviewed: Hand Arm Vibration Syndrome (HAVS) monitoring

2.28 The 14/15 audit found that the HAVS monitoring system was ineffective due to errors, omissions, incorrect points calculations and delays in submission of the monitoring forms. It was agreed that the monitoring arrangements would be reviewed and any failure to implement the system would be escalated. The current Shared Head of Health and Safety has proposed the purchase of vibration monitoring equipment which could be fitted to relevant applicable tools. Employees would have individual swipe cards, allowing them to sign in and out of the equipment. Exposure time could then be monitored via reports from the associated software system. CES managers have now agreed to the purchasing of this equipment and, in the future, will be undertaking monitoring on a dip sample rolling programme basis. In the interim, there is no effective monitoring system in place.

2.29 A revised completion date has been agreed for this action, please see point 10 of the Action Plan in Appendix 1. If the monitoring equipment is not purchased then alternative action will need to be considered. Area Reviewed: Health Surveillance

2.30 The 14/15 audit found that the processes for keeping the list of employees who require health surveillance up to date were not working effectively. It was agreed that occupational health training for managers would be undertaken and that the H&S service would have to continue to rely on managers to provide them with updates. Four training sessions were offered via the Work Force Development Unit during the financial year 15/16. The agreed action has been completed but there still seems to be issues receiving information from the services.

2.31 The list of employees requiring health surveillance is maintained by Business Support. However, there is no formal process to ensure that managers provide up to date information to the Business Support Officer. Managers must undertake an annual risk assessment of their site, identifying hazardous materials and activities that could potentially pose a threat to the health and safety of their staff. This would be an opportune time for managers to review and update the list of employees requiring health surveillance and it is recommended that this process is added to the risk assessment policy.

2.32 In order to sufficiently address the original finding, the agreed action for this area has been revised. Please see point 11 of the Action Plan in Appendix 1. 3 CONCLUSIONS

3.1 The service has successfully implemented five actions and partially completed two actions from the 13/14 and 14/15 audits.

3.2 Five agreed actions and partial actions have not been completed and have either been revised and/or a new timescale for completion has been agreed.

3.3 Two agreed actions are no longer appropriate to meet the requirements of the finding and have been revised.

## APPENDIX 1 – ACTIONS AGREED TO ADDRESS CONTROL WEAKNESSES

| Action Number | Report Reference | Issue | Risk | Agreed Action | Priority | Responsible Officer | Timescale | |---------------|------------------|----------------------------------------------------------------------|----------------------------------------------------------------------|--------------------------------------------------------------------------------|----------|---------------------|-----------| | 1 | 2.1 – 2.2 | Risks are not fully documented for services with an element of lone working | Staff are at increased risk of physical harm | The Health and Safety Auditor (AF) to take a sample of high risk service areas (e.g. social care) and assess the appropriateness of their documentation. | 2 | Head of Health and Safety | April 17 | | 2 | 2.1 – 2.2 | Risks are not fully documented for services with an element of lone working | Staff are at increased risk of physical harm | H&S to run a campaign to increase the awareness of the necessity of completing lone working risk assessments. | 2 | Head of Health and Safety | June 17 | | 3 | 2.4 – 2.7 | There is no single premises register in place, identifying the health and safety obligations the council has for each property | Services may not be provided to properties that require it | H&S to regularly liaise with Property Services, Facilities Management and Housing to ensure there is corporate oversight and that all obligations are being met. | 2 | Head of Health and Safety | April 17 | | 4 | 2.4 – 2.7 | There is no single premises register in place, identifying the health and safety | Services may not be provided to properties that require it | Premises registers for each H&S service to be compared with assets listed on | 2 | Head of Health and Safety | April 17 | | | | obligations the council has for each property | Techforge to ensure that they are complete. | Property Services will now forward a report on a quarterly basis, detailing all acquisitions and disposals for the period. H&S service will update their premises registers to reflect changes. | 2 | Head of Health and Safety | Complete | |---|---|---|---|---|---|---|---| | 5 | 2.4 – 2.7 | There is no single premises register in place, identifying the health and safety obligations the council has for each property | Services may not be provided to properties that require it | | | | | 6 | 2.17 | FRA actions are not followed up in a manner that provides the organisation with assurance over the management of fire risk | Actions from FRAs may not be completed, increasing the likelihood and impact of a fire | Complete the risk rating of properties requiring fire risk assessments. | 3 | Head of Health and Safety | Oct 16 | | 7 | 2.18 – 2.19 | FRA actions are not followed up in a manner that provides the organisation with assurance over the management of fire risk | Actions from FRAs may not be completed, increasing the likelihood and impact of a fire | Formalise the follow up and escalation processes, stating trigger points which would instigate these processes. | 3 | Head of Health and Safety | Oct 16 | | 8 | 2.21 – 2.23 | Asbestos risk registers and associated asbestos management plans are not being reviewed | Reviews are not taking place which could mean that changes that affect asbestos | Undertake a search of all premises files to identify the properties with missing reviews and management | 3 | Head of Health and Safety | Dec 16 | | | | | | | | | |---|---|---|---|---|---|---| | | | reviewed in council occupied non-domestic premises in accordance with statutory requirements | management may not be identified. | plans. Ensure coverage of these properties in the next review programme. Requirements for asbestos checks for commercial properties to be communicated by Property Services in a timely fashion, as per action 3. | | | | 9 | 2.24 – 2.26 | There are no up to date lists of site representatives for asbestos and legionella | Asbestos and legionella risks may not be managed appropriately, increasing the likelihood of exposure to asbestos or legionella bacteria | Complete the review of SALOs and SLRs by chasing and escalating review forms with the ‘responsible officer’ field left blank. | 2 | Head of Health and Safety Sep 16 | | 10 | 2.28 – 2.29 | HAVS monitoring is incomplete because of missing, delayed, inaccurate or incomplete monitoring forms | An employee may develop HAVS because frequent exceeding of the safe limit was not identified and addressed | A decision will be made as to how the HAVS monitoring system will operate in the future. | 2 | Head of Health and Safety Sep 16 | | 11 | 2.30 – 2.32 | The processes for keeping the list of employees who require health surveillance up to | Early signs of ill health are not identified because health surveillance is not undertaken | Adjust the risk assessment policy to ensure that managers are required to provide an annual | 3 | Head of Health and Safety April 17 | | Date are not working effectively | Update of employees requiring health surveillance to Business Support. |

\*The priorities for actions are:

Priority 1: A fundamental system weakness, which presents unacceptable risk to the system objectives and requires urgent attention by management.

Priority 2: A significant system weakness, whose impact or frequency presents risks to the system objectives, which needs to be addressed by management.

Priority 3: The system objectives are not exposed to significant risk, but the issue merits attention by management.